Family Survey

Q1A.Enter client’s ID number: ______

Q2.Enter the Interview Start Time (XXX or XXXX): ______

Q3.Enter the Interview End Time (XXX or XXXX): ______

Q4.Enter the Area Code and first Three Digits of the Telephone Number:______

INTERVIEWER, DIAL THE TELEPHONE NUMBER

6 – (access code) - ## - (area code) XXX – XXXX

INTRODUCTION

Q5.Hello, my name is ______, and I’m calling from the Washington Institute at the University of Washington. We have been asked by the Mental Health Division of the Department of Social and Health Services to talk with people about the mental health services their children have received. Your phone number was picked by chance from a list of people whose children received services within the last 6 months.

May I please speak to the primary caregiver of [child’s name]?

Q5A. Can you tell me your relationship to [child’s name]? ______

A pink colored letter was mailed to your family recently describing the study. Do you remember receiving it?

Q5B.

  1. Yes
  2. No ------ [INTERVIEWER READ: It was a brief letter to let people know that

we would be calling.]

Q6.The interview questions ask about your child’s experiences with his or her mental health service provider. Information from the study will be used to evaluate and improve the mental health program in Washington State. Your answers won’t be used to change or reduce any benefits that your child has a right to receive.

This interview is completely voluntary and has been approved by The Department of Social and Health Services. The information that you provide will remain confidential. Parts of this interview may be monitored by my supervisor, to check my work. Only the researchers at the Washington Institute will have all study information about you. Information that could identify you will be destroyed [XXXXXXXXX]. The interview takes about 15 minutes. If I come to any question that you would prefer not to answer, just let me know and I will skip over it. OK?

  1. Yes
  2. No, Not a Convenient Time --- [INTERVIEWER, ASK: When would be a good time to

call back?]

[INTERVIEWER: RECORD TIME AND NAME ON

CALL RECORD.]

  1. No ------ [INTERVIEWER: SKIP TO Q ___ and enter your initials

and the termination code.]

Great! I’m going to ask you several questions about the services you received OVER THE LAST 6 MONTHS.

Answer whether you Strongly Disagree, Disagree, Are Undecided, Agree or Strongly Agree

(1 = Strongly Disagree, 2 = Disagree, 3 = Are Undecided, Agree = 4 or 5 = Strongly Agree)

Q7. / Overall, I am satisfied with the services my child received. / 1 / 2 / 3 / 4 / 5
As a result of the services my child or my family received:
Q8. / My child is better at handling daily life. / 1 / 2 / 3 / 4 / 5
Q9. / My child gets along better with family members. / 1 / 2 / 3 / 4 / 5
Q10. / My child gets along better with friends and other people. / 1 / 2 / 3 / 4 / 5
Q11. / My child is doing better in school and/or work. / 1 / 2 / 3 / 4 / 5
Q12. / My child is better able to cope when things go wrong. / 1 / 2 / 3 / 4 / 5
Q13. / I am satisfied with our family life right now. / 1 / 2 / 3 / 4 / 5
Feedback about the services I received:
Q14. / I helped to choose my child’s services. / 1 / 2 / 3 / 4 / 5
Q15. / I helped to choose my child’s treatment goals. / 1 / 2 / 3 / 4 / 5
Q16. / The people helping my child stuck with me no matter what. / 1 / 2 / 3 / 4 / 5
Q17. / I felt my child had someone to talk to when he/she was troubled. / 1 / 2 / 3 / 4 / 5
Q18. / The people helping my child listened to what he/she had to say. / 1 / 2 / 3 / 4 / 5
Q19. / I was actively involved in my child’s treatment. / 1 / 2 / 3 / 4 / 5
Q20. / The services my child and/or family received were right for us. / 1 / 2 / 3 / 4 / 5
Q21. / The location of services was convenient for us. / 1 / 2 / 3 / 4 / 5
Q22. / Services were available at times that were convenient
for us. / 1 / 2 / 3 / 4 / 5
Q23. / If I need services for my child in the future, I would use these services again. / 1 / 2 / 3 / 4 / 5
Q24. / My family got the help we wanted for my child. / 1 / 2 / 3 / 4 / 5
Q25. / My family got as much help as we needed for my child. / 1 / 2 / 3 / 4 / 5
Q26. / My child and family’s needs determined my child’s treatment goals. / 1 / 2 / 3 / 4 / 5
Q27. / Staff treated me with respect. / 1 / 2 / 3 / 4 / 5
Q28. / Staff understood my family’s cultural traditions. / 1 / 2 / 3 / 4 / 5
Q29. / Staff respected my family’s religious/spiritual beliefs. / 1 / 2 / 3 / 4 / 5
Q30. / Staff spoke with me in a way that I understood. / 1 / 2 / 3 / 4 / 5
Q31. / Staff were sensitive to my cultural/ethnic background. / 1 / 2 / 3 / 4 / 5
Q32. / I felt discriminated against while trying to get services here. / 1 / 2 / 3 / 4 / 5

Q33.Is your child....

[INTERVIEWER: Ask, if necessary]

1.Female?

2.Male?

Q34.What is your child’s birth date?

______/______/______

month day year

Q35.What is the race or ethnic group of your child?

a.Native American or Alaskan Native

b.Asian or Oriental

c.African American or Black

d.Hispanic or Latino

e.White, non-Hispanic

f.Pacific Islander

  1. Some Other Race or Ethnic Group

Q.36.(please name) ______

Q37.Is [child’s name] currently in school ?

  1. Yes
  2. No ------ [INTERVIEWER: SKIP TO Q. 39]

Q38.What grade is your child in school

______grade

Q39.What is the highest grade that [child’s name] completed?

______grade

Q40.Who is [child’s name] living with now?

(INTERVIEWER: Select Only One)

  1. With one parent (include step parent)
  2. With both parents (include step parent)
  3. With another family member (not parent (s)).
  4. Foster home
  5. Therapeutic foster home
  6. Crisis shelter
  7. Homeless shelter
  8. Group home
  9. Residential treatment center
  10. Hospital
  11. Local jail or detention facility
  12. State correctional facility
  13. Runaway/homeless
  14. I live with someone other than above

Q41. (Who do you live with other than above? ______)

Q41. Do you have Medicaid insurance

  1. Yes
  2. No

Q41. INTERVIEWER: ENTER YOUR NAME!

Q42. Enter the termination code